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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Wednesday, September 17, 2014

Suicide in doctors and others: remembering and preventing it if we can

Recently, SASS-MoKan,
our local suicide survivors’ support group, held its annual Remembrance Walk. I
have written about these in the past, and have included the fact that my
personal interest in the issue of suicide is the fact that my older son, Matt,
committed suicide in 2002, just after he turned 24. At the time, everything
seemed to be going fine in his life, and it came as a real surprise to his
family, his close friends, everyone.

The Remembrance Walk is a lovely ceremony. Following a lap
around a good-sized park, there is a ceremony. All the survivors stand on the
grass in a circle, and the names of all those they have lost are read; at the
end, a flight of doves is released. It is caring, and it is supportive. Of
course, the ceremony also brings out the pain and sadness of our losses.

Matt died nearly 12 years ago, but I know others who have
lost children very recently. I can tell them that the acute agonizing pain that
feels as if it will never ease does, but they cannot and should not believe. It
becomes less acute, less sharp, less all-consuming every minute, but it never
goes away.

Recently, an Op-Ed in the New York Times by Pranay Sinha discussed “Why
do doctors commit suicide?”. Because I am a doctor, and one who many of my
colleagues know had a suicide in my family, several people shared this with me,
although I’d already seen it. The article provides the perhaps shocking
information that the suicide rate among physicians is twice the national
average. Beyond this, however, it focuses on residents, doctors in training,
and the enormous stresses that they are under, not further discussing the
reasons why doctors in general have such high suicide rates. This is not
surprising, as Dr. Sinha himself is a first-year resident (at Yale) and is
obviously acutely aware of the stresses and strains of residents.

I know that this is true; I was a resident (a long time ago,
in the last millennium) and I work every day with residents. It is a hard job;
although these people will become, in a few years, full-fledged physicians who
will range from very well-paid to extremely well-paid, they are, as residents,
working for about the US average wage, but up to 80 hours a week, often with
life and death in their hands. That this is fewer hours than residents used to work is good, but is of limited
comfort to them. The point is that the residency is a big stress, and it occurs
at an age when many people, especially males, are already at risk. The
important issues that are addressed in this piece, and in several of the letters
written in response to it, are the idea that doctors are supposed to be
all-knowing, infallible, unwilling to admit mistakes or weakness. The op-ed and
the letters make clear how obviously unreasonable and burdensome that this is,
for all doctors and possibly even more for these young doctors who are even
more aware, inside, of what they don’t know and are terrified of showing it.

This is National Suicide Prevention Month, which is why the
remembrance walk is in September, and why there are such articles appearing. NPR
recently ran a program on the increase in the number of suicides in
middle-aged men has increased by 50% since 1999; older men have always had the
highest suicide rate, followed by adolescents and young men, but this increase
in men aged 45-65 is new. Some suggestion is that it is the economic downturn,
which hit poor people well before the “official” recession; it is lower-income
men who had the highest rates in this age group. Robin Williams’ recent suicide
was widely covered; I doubt that National Suicide Prevention Month entered into
his decision. Interestingly to me, many of the commentators focused on the “how
surprising, he was so funny, he made us laugh, who would have guessed” angle,
while others have discussed how he, like many comedians, needed the public
attention but was lost when alone. I suspect Williams was bipolar; certainly
many of his activities have suggested an ongoing depression while his outer
persona was so often manic.

What many of the articles, including the Op-Ed, do not
discuss, however, is the fact that most suicides in the US are caused by
depression, a disease. It may be unipolar (“just” depression) or bipolar
(“manic depression”), but it is potentially fatal. The stresses of being a doctor, or being a
resident, are tremendous and cause people who are depressed to go “over the
edge” and commit suicide, but it is important to remember that most people
undergoing the same stresses do not. The underlying condition usually needs to
be present for the precipitating cause to be fatal. I have previously cited
what I consider to be one of the best discussions of this issue, “The trap of
meaning: a public health tragedy” by CG Lyketsos and MS Chisolm in JAMA.[1]

National Suicide Prevention Month, and the activities
associated with it, are critically important for raising awareness about a
condition that kills 40,000 Americans a year, but is often kept secret, through
shame. When I became a member of the club no one wants to be in, what are
called suicide survivors (although the meaning is family and friends of someone
who has completed suicide, rather than those who have personally survived a
suicide attempt), I found out lots of people I knew were also members. They had
parents, children, siblings, close friends who had committed suicide, but I
didn’t know. We often don’t talk about our pain, but the sadness of losing a
child seems to many to be more ok to talk about if it was a medical disease, or
car accident, or homicide, than if it was suicide. But the loss is the loss;
the pain is the pain.

I don’t have the optimism that some do about being able to
prevent suicide in specific cases. I do believe that early diagnosis and
treatment helps; I believe that being aware of the warning signs is important,
and I will never know how many times having those who loved him around might
have prevented my son from killing himself before he finally did. I can only
hope that more awareness and discussion about this condition will make a
difference for some, and perhaps many.